Healthcare Provider Details

I. General information

NPI: 1205431707
Provider Name (Legal Business Name): YANCY MEJIA RADT I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3316 W BEVERLY BLVD
MONTEBELLO CA
90640-1537
US

IV. Provider business mailing address

3316 W BEVERLY BLVD
MONTEBELLO CA
90640-1537
US

V. Phone/Fax

Practice location:
  • Phone: 323-722-4529
  • Fax: 323-722-4450
Mailing address:
  • Phone: 323-722-4529
  • Fax: 323-722-4450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1409971120
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: